LEGACY NURSING AND REHABILITATION Nursing Home


LEGACY NURSING AND REHABILITATION (CCN: 676174) is a For profit - Corporation facility located in CAMERON, TX (76520). The facility has an overall rating of 3/5, health inspection rating of 3/5, and a staffing rating of 2/5. It offers 104 certified beds and maintains an average of 62.9 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.42512 total hours per resident per day. It has been certified since March 1, 2008 and the last listed health inspection was on June 10, 2022, The facility is located in Milam county and provides senior and nursing home care.

LEGACY NURSING AND REHABILITATION Summary


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Provider Name: LEGACY NURSING AND REHABILITATION

Address: 2202 N TRAVIS AVE, CAMERON, TX 76520

Phone: (254) 697-6564

County: Milam (795)

Ownership Type: For profit - Corporation

Certified Beds: 104

Average Residents Per Day: 62.9 ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: CAMERON OPCO LLC

First Approved Date: March 1, 2008

Affiliated Entity: LEGACY NURSING & REHABILITATION (307)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 3 ()

Health Inspection Rating: 3 ()

QM Rating: 3 ()

Long Stay QM Rating: 2 ()

Short Stay QM Rating: 3 ()

Staffing Rating: 2 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.11120, LPN Staff Hours Per Day: 1.1214, RN Staff Hours Per Day: 0.1925, Licensed Staff Hours Per Day: 1.3139

Total Nurse Staff Hours Per Day, per resident: 3.42512

Weekend Nurse Staff Hours: 2.90130, Weekend RN Staff Hours: 0.1683

PT Staff Hours Per Day, per resident: 0.0197

Nurse Staff Turnover: 54.4, Nurse Turnover Note:

RN Turnover: , RN Turnover Note: 6

Admin Left Number: 0, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 1.8989, Case Mix LPN Hours Per Day: 0.7444, Case Mix RN Hours Per Day: 0.3800

Adjusted Nurse Aide Hours Per Day, per resident: 2.26501, Adjusted LPN Hours Per Day: 1.1116, Adjusted RN Hours Per Day: 0.1908

Total Adjusted Nurse Hours Per Day, per resident: 3.57084

Adjusted Weekend Nurse Hours Per Day, per resident: 3.02473

Health Survey Dates and Scores: Cycle 1: 2022-06-10 (Score: 32), Cycle 2: 2019-10-09 (Score: 44), Cycle 3: 2018-10-03 (Score: 36)

Total Weighted Health Score: 36.667

Reported Incidents: 1, Substantiated Complaints: 0

Infection Control Citations: 1

Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 16463.53, Payment Denials Number: 0, Total Penalties Number: 1

Location and GPS: 2202 N TRAVIS AVE,CAMERON,TX,76520 (30.8676, -96.973)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2022-06-10

Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-06-30

Citation on 2022-06-10

Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-06-30

Citation on 2022-06-10

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-06-30

Citation on 2022-06-10

Type: Health, Deficiency: Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-06-30

Citation on 2019-10-09

Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-22

Citation on 2019-10-09

Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-19

Citation on 2019-10-09

Type: Health, Deficiency: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-22

Citation on 2019-10-09

Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-11-05

Citation on 2019-10-09

Type: Health, Deficiency: Provide timely, quality laboratory services/tests to meet the needs of residents.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-11-05

Citation on 2019-10-09

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-11-05

Citation on 2019-10-09

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-11-05

Citation on 2022-02-11

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-16

Citation on 2018-10-03

Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-10-26

Citation on 2018-10-03

Type: Health, Deficiency: Provide enough food/fluids to maintain a resident's health.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-10-26

Citation on 2018-10-03

Type: Health, Deficiency: Provide timely, quality laboratory services/tests to meet the needs of residents.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-10-26

Citation on 2018-10-03

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-10-26


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-08-11

Type: Fire Safety, Tag: 0352, Version: New

Description: Properly install and monitor supervisory attachments on automatic sprinkler systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-09-02

Citation on 2023-08-11

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-09-02

Citation on 2019-10-09

Type: Fire Safety, Tag: 0004, Version: New

Description: Develop and maintain an Emergency Preparedness Program (EP).

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-30

Citation on 2019-10-09

Type: Fire Safety, Tag: 0039, Version: New

Description: Conduct testing and exercise requirements.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-30

Citation on 2019-10-09

Type: Fire Safety, Tag: 0344, Version: New

Description: Have an alternate power supply for its alarm system.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-30

Citation on 2019-10-09

Type: Fire Safety, Tag: 0352, Version: New

Description: Properly install and monitor supervisory attachments on automatic sprinkler systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-30

Citation on 2019-10-09

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-30

Citation on 2019-10-09

Type: Fire Safety, Tag: 0712, Version: New

Description: Have simulated fire drills held at unexpected times.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-25

Citation on 2019-10-09

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-10

Citation on 2018-10-02

Type: Fire Safety, Tag: 0291, Version: New

Description: Install emergency lighting that can last at least 1 1/2 hours.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-10-26

Citation on 2018-10-02

Type: Fire Safety, Tag: 0351, Version: New

Description: Install an approved automatic sprinkler system.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-10-05

Citation on 2018-10-02

Type: Fire Safety, Tag: 0352, Version: New

Description: Properly install and monitor supervisory attachments on automatic sprinkler systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-10-16

Citation on 2018-10-02

Type: Fire Safety, Tag: 0741, Version: New

Description: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-10-05

Citation on 2018-10-02

Type: Fire Safety, Tag: 0911, Version: New

Description: Meet requirements for the installation and maintenance of electrical systems.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-10-17